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Quarterly Claim Editing Update: First Quarter 2021

Horizon BCBSNJ is implementing updates to our claim editing rules and processes for the fourth quarter of 2020 as noted below.

  • On January 1, 2020, we implemented claim editing updates related to rules/guidelines implemented by the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) that will impact claims for services provided to patients enrolled in fully insured, Medicare Advantage and State Health Benefits Program/School Employees' Health Benefits Program (SHBP/SEHBP) plans.

    Details of these updates may be accessed by visiting CMS web pages Quarterly PTP and MUE Version Update Changes and PTP Coding Edits.
  • On or about February 19, 2021, we will implement additional quarterly claim editing updates which include the NCCI edits noted above for all other members as well as the claim edits noted in our Quarterly Claim Editing Update Report. We encourage you to review details within this report.

    The effective date of the changes noted in this report will be January 1, 2020 (unless otherwise specified in the report). Changes noted in this report will apply to all claims finalized on and after February 19, 2021.

    Claims finalized before this update is implemented will not be adjusted following the implementation for the sole purpose of ensuring conformity with these claim editing rules, however, if a claim that was finalized before the implementation is adjusted after the implementation for other reasons, the updated claim editing rules will be applied.

Read more about our Claim Editing Policies.

If you have questions, call a Physician Services representative at 1-800-624-1110 or an Institutional Services representative at 1-888-666-2535, weekdays, between 8 a.m. and 5 p.m., Eastern Time.

Clear Claim Connection™
Participating physicians, other health care providers and facilities can review how updated claim editing rules impact reimbursement for certain code combinations by using the Clear Claim Connection available via NaviNet®.

To access Clear Claim Connection, log in to and:

  • Select Horizon BCBSNJ from the My Health Plans menu.
  • Mouse over Claim Management.
  • Click Clear Claim Connection.


Clear Claim Connection™ and NaviNet® are registered trademarks of NaviNet, Inc.

Published on: January 19, 2021, 11:16 a.m. ET
Last updated on: April 22, 2021, 05:34 a.m. ET